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Li S, Winston P, Mas MF. Spasticity Treatment Beyond Botulinum Toxins. Phys Med Rehabil Clin N Am 2024; 35:399-418. [PMID: 38514226 DOI: 10.1016/j.pmr.2023.06.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2024]
Abstract
Botulinum toxin (BonT) is the mainstream treatment option for post-stroke spasticity. BoNT therapy may not be adequate in those with severe spasticity. There are a number of emerging treatment options for spasticity management. In this paper, we focus on innovative and revived treatment options that can be alternative or complementary to BoNT therapy, including phenol neurolysis, cryoneurolysis, and extracorporeal shock wave therapy.
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Affiliation(s)
- Sheng Li
- Department of Physical Medicine and Rehabilitation, McGovern Medical School, University of Texas Health Science Center - Houston, Houston, TX, USA; TIRR Memorial Herman.
| | - Paul Winston
- Division of Physical Medicine and Rehabilitation, University of British Columbia, Victoria, British Columbia, Canada; Canadian Advances in Neuro-Orthopedics for Spasticity Consortium, Victoria, British Columbia, Canada
| | - Manuel F Mas
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Puerto Rico, San Juan, Puerto Rico
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Zhang B, Darji N, Francisco GE, Li S. The Time Course of Onset and Peak Effects of Phenol Neurolysis. Am J Phys Med Rehabil 2021; 100:266-270. [PMID: 33595939 DOI: 10.1097/phm.0000000000001563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The aim of this study was to explore the time course of onset and peak effects of phenol neurolysis. DESIGN This is a retrospective chart review. Eleven patients with elbow flexor spasticity after brain injury were enrolled. The resting angle of the elbow joint was measured before and after the injection and up to 6 wks of follow-up. RESULTS Phenol injection was performed to 13 musculocutaneous nerves under ultrasound and electrical stimulation guidance. The resting elbow angles were 84.4° ± 25.8° (before injection), 116.6° ± 20.9° (immediately after injection), 121.2° ± 21.4° (2 hrs after injection), 127.2° ± 19.7° (24 hrs after injection), 145.4° ± 11.8° (7 days after injection), 145.5° ± 10.4° (14 days after injection), and 150.3° ± 12.2° (6 wks after injection; N = 7). The mean resting angle was statistically different among the time points from preinjection to 14 days after (F2.625, 31.505 = 36.805, P < 0.01). Post hoc tests revealed that significant improvements existed immediately after and 7 days after the injection (P < 0.01 for both). The effects seemed to reach its peak in 7 days. The effect sizes immediately and 7 days after the injection were 1.37 and 3.04, respectively. The immediate effect accounted for approximately 60% of the maximal effect. CONCLUSIONS Phenol neurolysis has an immediate effect on spasticity reduction and reaches its peak effect around 1 wk after injection.
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Affiliation(s)
- Bei Zhang
- From the Department of Physical Medicine and Rehabilitation, McGovern Medical School University of Texas Health Science Center-Houston, Texas (BZ, GEF, SL); TIRR Memorial Hermann Hospital, Houston, Texas (BZ, ND, GEF, SL); and H. Ben Taub Department of Physical Medicine and Rehabilitation, Baylor College of Medicine, Houston, Texas (ND)
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Affiliation(s)
- Amo Bakheit
- University Rehabilitation Research Unit, Mail Point 874, Level C, West Wing, Southampton General Hospital, Southampton SO16 6YD, UK Southampton
| | - DL McLellan
- University Rehabilitation Research Unit, Southampton General Hospital Southampton
| | - ME Burnett
- University Rehabilitation Research Unit, Southampton General Hospital Southampton
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Abstract
The use of phenol and alcohol nerve blocks in the treatment of localized muscle spasticity is well established. However, a number of questions relating to this procedure are still unanswered. This article presents experience of the effectiveness of chemical neurolysis in the treatment of severe lower limb muscle spasticity in 28 patients who had a total of 56 nerve blocks performed during a follow-up period of between four and 18 months.
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Affiliation(s)
- Amo Bakheit
- University Rehabilitation Research Unit, Southampton General Hospital, Southampton
| | - Dah Badwan
- University Rehabilitation Research Unit, Southampton General Hospital, Southampton
| | - DL McLellan
- University Rehabilitation Research Unit, Southampton General Hospital, Southampton
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Madanat JP, Geraci S, Jajoo P, Dunn K, Oreste A. Musculoskeletal pain as a novel complication after posterior tibial nerve block in stroke and traumatic brain injury patients. PM R 2011; 3:492-4. [PMID: 21570040 DOI: 10.1016/j.pmrj.2010.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Revised: 10/15/2010] [Accepted: 10/19/2010] [Indexed: 11/28/2022]
Affiliation(s)
- John Paul Madanat
- Department of Physical Medicine and Rehabilitation, 825 Northern Blvd, 1st Floor, North Shore-Long Island Jewish Health System, Great Neck, NY 11021, USA.
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Khot A, Sloan S, Desai S, Harvey A, Wolfe R, Graham HK. Adductor release and chemodenervation in children with cerebral palsy: a pilot study in 16 children. J Child Orthop 2008; 2:293-9. [PMID: 19308557 PMCID: PMC2656828 DOI: 10.1007/s11832-008-0105-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2007] [Accepted: 04/29/2008] [Indexed: 02/03/2023] Open
Abstract
PURPOSE A pilot study with short-term outcomes of a combined surgical and medical intervention for management of generalized lower limb spasticity, hip displacement and contractures of adductors in children with bilateral spastic cerebral palsy. METHODS A prospective cohort study of 16 children (9 boys and 7 girls) aged 2-6 years with bilateral spastic cerebral palsy was performed. At entry, 5 were classified as level III and 11 as level IV, according to the Gross Motor Function Classification System (GMFCS). The intervention consisted of surgical lengthening of adductor longus and gracilis combined with the phenolization of the anterior branch of the obturator nerve, using 1 ml of 6% phenol, applied under direct vision at the time of lengthening of adductor longus. The hamstring and calf muscles were each injected with Botulinum neurotoxin A at a dose of 4 U/kg/muscle. Serial clinical (hip, knee, ankle joint range of motion), radiographic (migration percentage) and functional data-taken from a functional mobility scale (FMS) or GMFCS-were collected at 3, 6, 12 and 24 months post-operatively. RESULTS There was a significant increase in hip abduction, knee extension (popliteal angle) and ankle dorsiflexion, maintained for 24 months; mean hip migration percentage decreased from 29 to 21% (P < 0.001). Using a validated mobility scale, significant improvements were noted in gross motor function. There were no complications related to the intervention. CONCLUSIONS The combined surgical-medical intervention resulted in a reduction of spastic hip subluxation and improvements in gross motor function, as determined by the FMS. The combined intervention is, thus, useful as a temporizing measure, before definitive decisions are made considering such interventions as dorsal rhizotomy, intrathecal baclofen and single-event, multilevel surgery.
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Affiliation(s)
- Abhay Khot
- The Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052 Australia
| | - Samuel Sloan
- The Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052 Australia
| | - Sameer Desai
- The Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052 Australia
| | - Adrienne Harvey
- The Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052 Australia ,Murdoch Children’s Research Institute, Flemington Road, Parkville, VIC 3052 Australia ,The University of Melbourne, Victoria, 3010 Australia
| | - Rory Wolfe
- Monash Medical Centre, Clayton Road, Clayton, VIC 3168 Australia
| | - H Kerr Graham
- The Royal Children’s Hospital, Flemington Road, Parkville, VIC 3052 Australia ,Murdoch Children’s Research Institute, Flemington Road, Parkville, VIC 3052 Australia ,The University of Melbourne, Victoria, 3010 Australia
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Abstract
Neuromuscular blockade via injection of alcohol, phenol, or botulinum toxin reduces the tone of overactive muscles in order to restore the appropriate balance between agonists and antagonists. Such a restoration allows improved stretch and increased resting length and can reduce the likelihood of contracture. Alcohol or phenol, injected onto the motor nerve, denatures proteins and promotes axonal degeneration. The onset of action is within hours, whereas the duration of action is variable, ranging from 2 weeks to 6 months and beyond. The advantages of alcohol or phenol chemodenervation lie in their low cost and lack of antigenicity. The disadvantages include the technical difficulty of the injections and significant risk for pain as a result of treatment. Botulinum toxins, purified forms of Clostridium botulinum exotoxins, are injected directly into muscle, where they cleave one or more vesicle fusion proteins, thus blocking release of acetylcholine at the neuromuscular junction. Three commercial products--two of serotype A and one of B--are available. Each differs in its unit potency, side effects, and duration of action. On average, botulinum toxin has a clinical onset of action approximately 12 to 72 hours after injection, with a peak effect at 1 to 3 weeks. Effects then plateau for 1 to 2 months, with patients often requiring reinjection approximately every 3 months. Side effects may include local discomfort at the site of the injection and excessive weakness of the injected or nearby muscles, although more distant effects may occur. Antibody formation is a significant clinical concern and eventually obviates treatment benefit in approximately 5% of patients. Switching serotypes may be effective, at least temporarily. Consensus dosing guidelines have been developed and are presented within. Numerous studies have suggested that botulinum toxin has a role in the care of children with spasticity or dystonia related to cerebral palsy, and may improve equinus, gait, upper extremity use, comfort, and care. Evidence of functional improvement remains equivocal in the severely impaired child; however, there is evidence for improvement in less impaired children. The optimal candidate for injectable neuromuscular blockade is one who has a limited number of muscles that need treatment, who does not have fixed contracture, and who retains selective motor control. The ultimate goal of treatment for the hypertonic child is to maximize function, comfort, and independence. Hypertonia is only one aspect of the upper motoneuron syndrome, which includes both positive and negative symptoms. The treatment program, in which chemodenervation is only one tool, requires a multidisciplinary evaluation and individualized plan to address the whole patient.
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Affiliation(s)
- Ann H Tilton
- Department of Neurology, Section of Child Neurology, Louisiana State University Health Science Center, New Orleans, LA, USA.
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Abstract
In children with spastic quadriplegia, also described as 'whole body involvement', spasticity can interfere with motor function, contributes to the development of deformities and adversely impacts on care, positioning, and comfort. In this population, spasticity interventions address goals such as improving comfort, reducing pain, easing the burden of carers, slowing the progression of musculoskeletal deformities and perhaps improving function. Children with severe diplegia are distinguished from those with quadriplegia by their ability to ambulate, as well as by a greater emphasis being placed on functional motor goals even though similar treatment modalities are often employed to manage spasticity. The many treatment options currently available include, but are not limited to, botulinum toxin type A, phenol neurolysis, oral medications, intrathecal baclofen, selective dorsal rhizotomy, and orthopaedic surgery. The integration of these treatment modalities can help to optimize the overall care and function for a child with spastic quadriplegia or severe diplegia. However, the development of a management programme is complex and needs to take into account many factors, including age, weight and nutritional status, rate of progression of musculoskeletal deformities, developmental potential, comorbid conditions, current functional status and prognosis, and family and patient treatment goals. Children with marked spasticity are likely to benefit from a combination of interventions, rather than a single treatment modality. Because of these complexities, management should be planned and coordinated by a multidisciplinary team of medical and allied health professionals which recognizes the central role of the family in all decisions. Once the special characteristics of the child with spastic quadriplegia and the various treatment options are understood, outcomes can be maximized.
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Affiliation(s)
- M E Gormley
- Department of Physical Medicine and Rehabilitation, Gillette Children's Specialty Healthcare, St. Paul, Minnesota 55101, USA.
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Karen S. G. Chua, Keng-He Kong. Clinical and functional outcome after alcohol neurolysis of the tibial nerve for ankle?foot spasticity. Brain Inj 2001. [DOI: 10.1080/02699050121181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
The use of phenol motor nerve blocks is advantageous in the early period of acquired spasticity (ie, that occurring following traumatic brain injury or incomplete spinal cord injury), when increased muscle tone is often the most severe. Because acquired spasticity is dynamic and usually improves slowly, a temporary treatment method used to ameliorate increased muscle tone is desirable. Phenol nerve infiltration provides a temporary motor nerve block that lasts for weeks or months. It allows passive limb mobilization in a comprehensive rehabilitation program that attempts to prevent fixed soft tissue contractures. Permanent or irreversible methods such as operative tendon lengthening, muscle release or recession, or neurectomy are usually best delayed until the spasticity has become static, when the need for surgical correction becomes more firmly indicated, and outcomes of operative intervention are more predictable. Although phenol nerve blocks were initially administered at the spinal cord level to control spasticity, the potential side effects have caused a loss of popularity of this method of administration. The safer and more common use of phenol infiltration at the peripheral nerve level is now more accepted for brain injury and spinal cord injury patients. This report reviews the indications, current concepts, and development of the different methods used to administer phenol nerve blocks. Comparisons to other methods to control spasticity are discussed.
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Affiliation(s)
- M J Botte
- Department of Orthopedic Surgery, University of California, School of Medicine, San Diego, USA
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Abstract
In a previous report, we described heretofore undiscovered possibilities that neuropathic pain and spasticity may share some common pathophysiological mechanisms. Currently, systemically delivered local anesthetics are being used for the evaluation and treatment of neuropathic pain. We present a case describing the treatment of spasticity of spinal origin with continuous subcutaneous infusion of 0.75% bupivacaine in a patient who did not respond to traditional treatments and has become tolerant to intrathecal baclofen.
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Affiliation(s)
- B S Goodman
- Department of Rehabilitation Medicine, Emory University School of Medicine, Atlanta, GA
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Abstract
Ninety-two tibial nerve blocks with phenol were performed in 59 patients for treatment of severe spasticity of the foot. The Achilles tendon reflex was abolished, ankle clonus was eliminated and resistance to passive stretch was reduced substantially following the procedure in all patients. Significant functional gains were observed as a result of decrease in spasticity with long-term follow-up averaging 28.7 months (range 14-60). The simplicity of the procedure, the functional results observed with long-lasting effects, and the lack of serious complications, would suggest the more widespread use of this procedure in the treatment of the spastic foot.
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Affiliation(s)
- C R Petrillo
- Section of Physical Medicine and Rehabilitation, Norwalk Hospital, Connecticut 06856
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